• I have no disclosures. • I am thankful to my patients who I have had Opioid Use & Pregnancy the opportunity to learn from. Soraya Azari, MD Associate Professor of Medicine Learning Objectives Case 1 • EB is a 23yo F with a hx of HTN, G1P0 at 19 weeks • To be able to describe best practices for gestation that was found living in an encampment in management of opioid use disorder in pregnant San Francisco. She is injecting opioids and women methamphetamine and sharing needles. She uses • To have some understanding of what happens in tobacco (1-1.5ppd). She denies use of alcohol, cocaine, or benzodiazepines. narcotic treatment programs • Partner is HIV positive; she is negative to the best of her • To cultivate empathy for women that are knowledge. pregnant and struggling with substance use • She describes intermittent periods of opioid disorders withdrawal. She had one OB appointment at Kaiser w/sono providing EDD; otherwise no prenatal care. She • To be able to list evidence-based interventions for desires to keep the pregnancy. treatment of neonatal abstinence syndrome • She is taking no medications and has no allergies.
Case 1 continued Question • She used to be living with her mother but is Which of the following is the best course of action: no longer (was on her kaiser insurance plan). A. Admit for acute detoxification FOB HIV positive, unclear whether he is on 38% 33% meds (she is aware of his status) B. Admit to a residential treatment program for behavioral interventions • No current employment; receiving general C. Refer to methadone maintenance 14% assistance benefits 10% program 5% D. Offer buprenophine-naloxone E. Offer IM extended-release naltrexone . . . . . . . . . . . . . . . s f i r a i l a i t a x m n e o a l l - e t i e e e t r n n n - d e o i d h e e d d p d t i a u s h o n e n e c r t a e e t a r x r m e o o p u f t o M t b t t I m i i r r m e e r e d d f f f e f A A O O f R Background: OUD & Pregnancy overprescribing was not the sole cause of the problem. While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions, and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and other substances. Prevalence of OUD in Deliveries : Increase 333% from 1999 – 2014 : 2011 2016 2018 1.5 cases/1000 delivery hospitalizations 6.5 cases/1000 delivery hospitalizations MMWR: CDC Overdose WORST: West Virginia and Vermont Opioid Guidelines rising Pew Research, SSA; Am J Pub Health 2018 Overdose
Prescribing Patterns Let’s Back Up: Screening & Diagnosis • Screening – ACOG recommendation for universal screening. Options: 4Ps Plus, NIDA Quick Screen, and CRAFFT (<26yo) – 4P’s Plus (yes to anything = positive screen) • Parents : Did either of your parents ever have a problem with alcohol or drugs? • Partner : Does your partner have a problem with alcohol or drugs? • Past : Have you ever drunk alcohol? • Pregnancy : In the month before you knew you were pregnant, how many cigarettes did you smoke? – How many beers/wine/liquor did you drink – How many opioids did you use (non-medically) J Pain Res. 2017; 10: 383–387. Screening & Diagnosis Diagnosis • Urine toxicology testing – Obtained only with patient’s consent and in compliance with state laws – Pregnant women should be informed of the possible consequences of a positive test (including mandatory reporting) – Pros: increase detection of use – Cons: only shows recent use; imperfect sensitivity; does not test for many synthetic drugs; risk FP; need to understand how to interpret – Universal Screening experiments*: • Cincinnati community hospital: 5% positive (3.2% opioids) – 20% of the opioid-positive samples were in moms without screening risk factors » 37% of these (7/19): required admission to special care nursery for NAS * Not standard of care Am J Psychiatry 2013;170:834-851
Opioid Use Disorder Diagnosis Case Continued • EB first used substances at age 13 (cigarettes, – Opioid use disorder alcohol) and tried prescription opioids at 14, • 4 Rs which were prescribed to her mother. Using – Risk of bodily harm Use of needles, sharing needles opioids made her feel less anxious and like she – Relationship trouble Estranged from mother could “act like herself.” – Role failure Homeless, not working – Repeated attempts to cut back • She quickly escalated to daily use. When it • 4 Cs became difficult to take her mother’s pills, she – Loss of Control started dating an older man that introduced her – Continued use despite harm Injection of heroin despite pregnancy to heroin, which was less expensive and more – Compulsion (time & activities) easily obtained. – Craving • She left home repeatedly to spend time with her • Withdrawal and tolerance male partner. She hid her use from her family. Having periods of withdrawal Question Language & Stigma In cohort studies of women who are pregnant • Stigma: attribute, behavior, or and have a substance use disorder, what condition that is socially percentage have a history of adverse childhood discrediting events (ACE)? 47% – Cause A. 30% – Controllability B. 50% • WHO study, 18 most stigmatized 27% C. 70% social problems (including 20% D. 90% criminal behavior): drug UD (#1) 7% • Stigma – large factor in the “treatment gap” % % % % 0 0 0 0 3 5 7 9 Kelly, Wakeman, and Saitz. Am J Med. 2015;128(1): 8-9..
Causes and Controllability • Causes • Controllability – Iatrogenic – Addiction is a chronic, relapsing (overprescribing of brain disorder characterized by opioids) compulsive drug seeking and use despite harmful consequences as – Genetics well as neurochemical and – Adverse childhood molecular changes in the brain events – Person-related: Early age of first use, “Risk taking” behavior, use of other substances Criminal Prosecution of Women with a Substance Use Disorder • 22 states, District of Columbia – use of any illegal substance during pregnancy constitutes child abuse – Minnesota, South Dakota, Wisconsin – grounds for court-ordered institutionalization regardless of woman’s wishes • WI: woman can be detained against her will for duration of pregnancy, fetus has court-appointed lawyer, she can lose custody after birth, and proceedings are mostly secret • 24 states, DC – require health care professionals to report • https://www.guttmacher.org/state- policy/explore/substance-use-during-pregnancy Guttmacher Institute website
Who Is this Person? • Likely, a victim of severe trauma – Expectant mothers from FQHCs in Philadelphia area, examining 7 ACEs: 72% had at least 1 ACE (52% physical, 18% shooting); dose-response w/SU – S Africa study of women with alcohol use disorder – 64% with exposure to some form of trauma (childhood abuse or IPV); 48% both • Has also probably inherited severe poverty: “intergenerational disadvantage” • Also, likely depressed: 30% with mod-sev depression Chung et al. Acad Pediatr. 2010;10(4): 245-51.Choi KW et al. BMC Pregnancy Childbirth. 2014;14:97. Nytimes.com Holbrook et al. Am J Drug Alc Abuse 2012;38:575-9. Language & Stigma Case Continued • Study: Comparison of written vignettes about • EB had been trialed in one detoxification a patient in legal trouble given to doctoral- program at Kaiser in the past while on her level mental health and addiction clinicians. mother’s insurance, but relapsed. She tried • “substance abuser” several times to stop opioids herself once she • “having a substance use disorder” knew she was pregnant, but those attempts – Clinicians exposed to “substance abuser” term were more were unsuccessful also. likely to judge the person as deserving blame and punishment • Anti-Stigma • She was ashamed to tell her family about her pregnancy. Drug “abuser” or “PSA” Person with a substance use disorder “Dirty” utox Abnormal urine toxicology test “Addict” in and out of program Severe SUD with repeated treatment attempts Relapse Recurrence of chronic illness
Maintenance Treatment for OUD: Treatment: Terms Standard of Care Relapse Detox Prevention Office- Hospital Social Residential Based, MAD Model including Medication Mgmt Intensive Outpatient Residential Ambulatory 12 Step/ MAD MAD Peer Outpatient with MAT (i.e. Outpatient methadone) w/o MAT MAD = Medically Assisted Detoxification MAT = Medication Assisted Treatment Question Which of the following summarizes the evidence of buprenorphine versus methadone for pregnant women with OUD? A. Duration of neonatal abstinence syndrome is shorter in bupe-maintained women, compared to methadone 61% B. Fetal indicators (i.e., HR, HR variability, fetal activity) appear superior in methadone- maintained women 23% 11% C. Buprenorphine is better if the woman desires 5% to breast feed D. Methadone is associated with a higher risk of Duration of neonatal ab... Buprenorphine is better i... Methadone is associated... Fetal indicators (i.e., HR, .. congenital abnormalities
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